Molar pregnancy

I went in for my D&C follow-up appointment this past week only to find out that this last pregnancy (that ended in a miscarriage) was a molar pregnancy. What is a molar pregnancy, you ask? I had the same question. My OBGyn gave me information from the Mayo Clinic (view it here, or Google "Molar Pregnancy Mayo Clinic"). I'm going to use that source as well as What to Expect When You are Expecting by Heidi Murkoff, Arlene Eisenberg, and Sandee Hathaway (I have the third edition), the two sources I have used looking up molar pregnancy. My doctor said that sometimes Googling things leads to finding out really scary information and I've decided that I don't need more stress (he also told me to call him if someone tells me something upsetting that I want to ask about). I'm going to do my best explaining a molar pregnancy with those two sources.

There are two types of molar pregnancies: a complete molar pregnancy and a partial molar pregnancy. I had a partial molar pregnancy. What to Expect defines a complete molar pregnancy as "an abnormal mass, instead of a normal embryo, [that] forms inside the uterus after fertilization. The trophoblast-- the layer of cells that line the gestational sac-- converts into a clump of clear tapioca-like vesicles instead of the beginnings of a placenta" (pg 513). The Mayo Clinic says, "in a partial molar pregnancy, there's an abnormal embryo and possibly some normal placental tissue. The embryo begins to develop but is malformed and can't survive." What to Expect goes further and says, "if the fetus survives, it may be growth-restricted and have a variety of congenital abnormalities..." (pg 515).

What causes a molar pregnancy? To quote the Mayo Clinic:

A molar pregnancy is caused by an abnormally fertilized egg. Human cells normally contain 23 chromosomes. One chromosome in each pair comes from the father, the other from the mother. In a complete molar pregnancy, all the fertilized egg's chromosomes come from the father... In a partial molar pregnancy, the mother's chromosomes remain but the father provides two sets of chromosomes. As a result, the embryo has 69 chromosomes, instead of 46. This can happen when the father's chromosomes are duplicated or if two sperm fertilize a single egg.

A complete molar pregnancy "can be detected as early as eight or nine weeks" on an ultrasound (Mayo Clinic). The ultrasound may show: "no embryo or fetus, no amniotic fluid, a thick cystic placenta nearly filling the uterus, ovarian cysts" (Mayo Clinic). "As the pregnancy progresses, 1 in 5 women may pass a few of these tiny vesicles... The uterus is larger than expected and feels doughy rather than firm; no fetal heartbeat can be detected. Preeclampsia... or in some cases loss of weight and other indications of increased thyroid activity, may also be seen... The ovaries may also be enlarged because of the accompanying high levels of hCG" (What to Expect, pg 513).

In a partial molar pregnancy, "an ultrasound may show: a growth-restricted fetus, low amniotic fluid, a thick cystic placenta" (Mayo Clinic). What to Expect says the signs and symptoms "are similar to those of an incomplete or missed abortion. There is usually irregular... bleeding, no fetal heartbeat, and a uterus that is either small or normal for the length of the pregnancy. Only a small percentage of women with partial molar pregnancies have an enlarged uterus, as is common in a complete molar pregnancy" (pg 515).

Both sources list some physical signs. The Mayo Clinic listed: "dark brown to bright red...bleeding during the first trimester, severe nausea and vomiting, ...passage of grape-like cysts, rarely pelvic pressure or pain." What to Expect said, "The first sign of a molar pregnancy is usually an intermittent, though sometimes continuous, brownish discharge. Frequently normal morning sickness of pregnancy becomes abnormally severe" (pg 513).

This was my fourth pregnancy; I had no spotting and normal morning sickness. I felt nauseous and tired and did not suspect that something was wrong until our first ultrasound (read my blog post "Miscarriage"). We were told we could have our dates wrong or that the pregnancy was not progressing. With regular ultrasounds and blood work, it become apparent that I was miscarrying. The diagnosis of a partial molar pregnancy was a huge surprise.

Who is at a higher risk for a molar pregnancy? According to What to Expect, molar pregnancies occur "roughly 1 in 2,000 pregnancies in the United States... more often in women over forty-five than in younger mothers" (pg 513). The Mayo Clinic says, "molar pregnancy is uncommon, occurring in about 1 in every 1,000 pregnancies." The Mayo Clinic lists the at-risk groups:

• "Maternal age. A molar pregnancy is more likely for a woman older than age 35 or younger than age 20.
• "Previous molar pregnancy. If you've had one molar pregnancy, you're more likely to have another. A repeat molar pregnancy happens, on average, in 1 to 2 out of every 100 women.
• "Some ethnic groups. Women of Southeast Asian descent appear to have a higher risk of molar pregnancy."

How do you treat a molar pregnancy? "A molar pregnancy can't continue as a normal viable pregnancy. To prevent complications, the molar tissue must be removed" (Mayo Clinic). My OBGyn explained to me that complete molar pregnancies are visible on an ultrasound, while partial molar pregnancies often appear to be regular miscarriages, as mine did. Partial molar pregnancies are frequently discovered after a D&C when the tissue removed is examined by a doctor.

I did find something interesting in What to Expect regarding partial molar pregnancies on page 515, though I am unclear as to what circumstances would lead you to discover this was happening:

If a normal fetus is born, it usually turns out that it was part of a multiple pregnancy, with the partial mole belonging to a twin that had deteriorated... If the fetus is living and appears on ultrasound to be in good condition, the pregnancy will probably be allowed to continue.

Now that you understand what a molar pregnancy is, what are the complications involved with having a molar pregnancy? "A molar pregnancy can have serious complications-- including a rare form of cancer-- and requires early treatment" (Mayo Clinic). I'm going to copy the Mayo Clinics Complications section because it is very informative:

After a molar pregnancy has been removed, molar tissue may remain and continue to grow. This is called persistent gestational trophoblastic disease (GTD). It occurs in about 20% of women after a molar pregnancy-- usually after a complete mole rather than a partial mole.

One sign of persistent GTD is an elevated level of human chorionic gonadotropin (HCG)-- a pregnancy hormone-- in your blood even after the molar pregnancy has been removed. In some cases, an invasive mole penetrates deep into the middle layer of the uterine wall, which causes...bleeding. Persistent GTD can nearly always be successfully treated, most often with chemotherapy. Another treatment option is removal of the uterus (hysterectomy).

What to Expect says on pg 513:

Follow-up is important, since about 10-15% of molar pregnancies don't stop growing immediately. If blood hCG levels fail to return to normal, another D&C is performed. In the rare instances that hCG levels remain elevated after a second procedure, the physician will check for a new pregnancy or for the spread of molar tissue to the [lady parts] or lungs, which may be treated with chemotherapy. Very rarely, a molar pregnancy becomes malignant... so close medical follow-up is especially important, since this condition is very curable with early diagnosis and treatment.

How do they monitor your HCG levels? As stated, HCG is the pregnancy hormone. A negative result is a negative pregnancy test, meaning there were no HCG levels in your blood. My OBGyn wants me to come in for weekly blood tests until I have three negative tests in a row. Once that happens, he wants me to come in for monthly blood tests, again looking for negative results. If my HCG levels stay the same or go up, all of the molar matter has not been removed and we will have to look at our treatment options.

When can I get pregnant again? "Because pregnancy makes it difficult to monitor HCG levels," you are not recommended to get pregnant right away (Mayo Clinic). One of the first things my OBGyn did was write me a prescription for birth control. What to Expect says, "a new pregnancy is not recommended until hCG levels have been the same for one year" (pg 515). The Mayo Clinic says your doctor "may recommend waiting six months to one year before trying to become pregnant." My OBGyn recommended six months.

Will this affect my ability to get pregnant? According to the Mayo Clinic and What to Expect, it shouldn't. What to Expect states, "most women can have healthy babies after having a partial molar pregnancy, but since the risk of repeat exists, early ultrasound examination is important in future pregnancies to rule out that possibility" (pg 515). Mayo Clinic says, "if you've had a molar pregnancy, talk to your health care provider before conceiving again... During any subsequent pregnancies, your health care provider may do early ultrasounds to monitor your condition and offer reassurance of normal development." My OBGyn spent much time reassuring me that this should not affect our future chances of a successful pregnancy; I'm very optimistic though nervous about the chance of a repeat molar pregnancy.

The rare form of cancer is called choriocarcinoma, discussed in What to Expect. "Choriocarcinoma is an extremely rare cancer related directly to pregnancy. About half the cases develop when there is a molar pregnancy..." (pg 515). It is treated with chemotherapy. "With early diagnosis and treatment, survival is the norm and fertility is unaffected, though it is deferred for two years after treatment is complete and there is no evidence of residual disease" (pg 515). My OBGyn said that in his 18 years as a practicing OBGyn he has had 1-2 molar pregnancies a year and none have turned cancerous.

The Mayo Clinic also includes a section called Coping and Support:

Losing a pregnancy is devastating. Give yourself time to grieve. Talk about your feelings and allow yourself to experience them fully. Turn to your partner, family and friends for support. If you're having trouble handling your emotions, consult your health care provider or a counselor.

Miscarriages are heartbreaking. This is our second miscarriage and it doesn't get easier. Sometimes it is very hard to hear people say, "You can try again soon." It makes me feel like I'm taking the miscarriage too hard and that I shouldn't view it as losing a child. I feel like I've lost a child that I will never get to hold. It has taken me nearly a week to digest this latest development, the molar pregnancy. I feel so frustrated that we have to wait so long before we can start trying again. I'm praying hard about it because I feel so impotent. I've had two miscarriages and one of them was a molar pregnancy. Will I have another molar pregnancy? How long will we have to wait? I don't want to rush things and risk the serious complications of a molar pregnancy, but I want to start trying as soon as possible.

Ay me! sad hours seem long.